Doctor: Maryland needs assisted outpatient treatment so I can save my patients.

By Dr. Cynthia Lewis

The writer is a board-certified psychiatrist and director of Adult Psychiatric Emergency Services at the Johns Hopkins Hospital in Baltimore. The views expressed are hers and do not represent her employer. She can be reached at [email protected].

As a physician, I took an oath to first do no harm. Maryland’s lack of an assisted outpatient treatment law for civil commitment of those with serious mental illness, does not allow me to live up to that oath. This has left me and many of my colleagues disappointed, frustrated, demoralized and fearing for our patients’ lives.

My passion lies in treating people with severe mental illness such as schizophrenia and bipolar disorder, who are often among the most disenfranchised and vulnerable.

While working in the Community Psychiatry Program at The Johns Hopkins Hospital, I was able to form a collaborative relationship with most patients. However, voluntary services did not work for a small number of patients with severe mental illness who desperately needed treatment and would not, under any circumstances, seek it.

These patients, by no fault of their own, lacked insight into their illnesses. They genuinely had no awareness of their symptoms and were at a high risk of being victimized, arrested, or having their physical health deteriorate rapidly as they failed to treat comorbid conditions.

Later, as director of Adult Psychiatric Emergency Services, I saw the effects of remaining untreated. I am tired of seeing the same patients, sometimes multiple times a week, arrive in crisis, cycling in and out of the emergency department, hospital inpatient unit, homelessness and jails, their symptoms  : criminalized.

The pattern is familiar. After hospital discharge, a patient doesn’t engage with outpatient care. Medication is either refused or not taken consistently. Psychosis escalates until bad enough to warrant hospitalization, either voluntarily or involuntarily. We start the cycle again when they are admitted to the hospital, are treated, get better, and are deemed stabilized enough for discharge.

No physician believes that hopping from crisis to crisis does no harm to patients. But currently doctors have no ability to intervene in these situations outside of the hospital, and we are helpless to stop the cycle.

Something is broken in Maryland’s mental health system.

Maryland’s treatment laws lack a critical tool, one specifically for this vulnerable population. We are one of only three states whose civil commitment laws do not include assisted outpatient treatment, or AOT.

AOT is for those with severe mental illness and a history of not adhering to treatment, which can lead to repeated emergency department visits, hospitalization, arrest, homelessness, victimization, suicide and death. It adds court supervision to a treatment plan, ensuring that the system can’t simply drop patients when they leave the hospital. I knew AOT could be lifesaving for my most at-risk patients.

Maryland’s inaction is traumatizing those of us on the frontlines. A 20-year-old patient I highlighted in a presentation to my colleagues as someone who needed assisted outpatient treatment, died within a year of my presentation.

I knew she would die without a mechanism to keep her in treatment. My staff required intervention from our Crisis Management Team after her death, struggling with the guilt of being part of a mental health system that failed her. I am angry that my patients are needlessly losing their lives.

I am demoralized from calls with family members, begging me to help their loved ones who lack the insight to accept care. I am exhausted from having to explain that because they live in Maryland, their loved one is allowed to be ill and deteriorate. The state is more concerned about their right to refuse care than their right to lifesaving treatment.

I am angry that my taxpayer dollars are being spent on a broken system that fails us all and cannot provide lasting stabilization.

There have been efforts for many years to pass an assisted outpatient treatment law in Maryland. I gave personal testimony for AOT companion bills Senate Bill 480 and House Bill 823. Now that I understand that assisted outpatient treatment is what I’m lacking to help my patients, I am determined not to rest until I have it.

Maryland’s failure to act has led too many patients with severe mental illness to fall through the cracks. They are being denied any chance to lead safe, healthy and dignified lives.

Assisted outpatient therapy is a tool, and it’s a tool that is needed to save lives. My patients deserve to live in a state that will roll up its sleeves and fix what needs fixing. Let’s treat this like the emergency that it is.

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